MATERNAL RESUSCITATION

Education and TrainingThe King Edward

ExperienceLinda Long

CNS AnaesthesiaKing Edward Memorial Hospital for

Women

Case Presentation(Marisa)

►36 year old G2 P1

►2006; Previous non-elective caesarean section for pre-eclampsia, twins at 36/40

2008; pregnant despite presence of mirena coil; 32 weeks gestation

Normal pregnancy .........so far

Cardiac arrest in pregnancy

►Is a rare event 1:20-30,000

►Two patients to consider; mother + baby

►Speed and skill of response is critical for outcomes

►Staff do not retain information regarding resuscitation well, therefore `mock drills` essential at helping to prepare for the event.

►Crucial differences in resuscitating the pregnant patient

Physiological Changes

►Respiratory

• Dramatic increase in oxygen consumption

• Rapid onset of hypoxia

• Airway oedema

Physiological changes

►Gastro-intestinal

• Increased incidence of reflux• Delayed gastric emptying

Physiolgical changes

►Cardiovascular

• cardiac output less than 10% of normal during CPR

• increased heart rate

• Decreased resting blood pressure

• Aortocaval compression when supine

Implications for Resuscitation

►Increased risk of difficult airway

►Early endotracheal intubation ? With a smaller ET Tube

►? Cricoid pressure, diverts resources and may make intubation even more difficult

►Measures to prevent aortocaval compression

Uterine displacement

►Displacement of the uterus essential

►Cardiff Resuscitation wedge

►Manual displacement

Attempts at resuscitation may be futile if this is not performed

Gravid uterus picture

Perimortem Caesarean

►Promoted as early as 1986 to improve fetal survival

►Recommended time frame from maternal collapse to delivery of the fetus is 4-6 minutes (Katz et al 1986)

Perimortem Caesarean

EQUIPMENT

►

Perimortem Caesarean

►Caesarean packs kept in resuscitation trolleys in;

► Labour and birth suite

► Emergency centre

► Operating Theatres

►Soon to be implemented in other areas

TECHNIQUE

►Splash of betadine

►Disposable pre-loaded scalpel

►Midline abdominal incision recommended

What are we doing at KEMH?

►IN TIME course, multi-disciplinary obstetric emergencies workshop day

►Compulsory life support in-service for nurses and midwives

►Monthly mock scenarios – multi-disciplinary drills throughout the hospital

►Obstetric emergencies crisis course for anaesthetic registrars

Simulation Scenarios

►Simulation scenarios can be intermediate or high fidelity

►It allows staff to immerse themselves in the clinical proceedings without exposing patients to harm

► Realistic, pregnant manikins were required

Pregnant manikins!

To perform peri-mortem sections on!

CASE PRESENTATIONRemember Marisa ?

►36 year old G2 P1

►Previous non-elective caesarean section for pre-eclampsia, twins at 36/40 in 2006

►2008; despite presence of mirena coil; 32 weeks pregnant

►Uneventful pregnancy…………..so far!

Case Presentation Continued

►Collapsed at home on the sofa

►Brought in by ambulance

►Remained conscious during her transfer by ambulance

►Glasgow coma score was 15

►Heart rate 150

►Blood pressure unrecordable

Case presentation continued

►Transferred directly to labour and birth suite

►Patient became unresponsive, lost consciousness, and stopped breathing

►CPR commenced and code blue medical called

Management of Arrest

►Patient intubated and peri-mortem caesarean section performed in delivery suite

►On incision, four litres of blood in the abdominal cavity

►Code blue paediatric emergency called

Maternal Management

►CVC, arterial line and use of rapid infuser

►Given 170 units red cells, FFP, cryo and platelets

►Inotropes and vasopressin infusions to maintain systolic blood pressure at 90mmHg

Fetal delivery

►Male baby delivered at 8 mins from maternal collapse

►pH was 6.9

►Heart rate < 60

►Apgar score was 1 at birth, 6 five mins later

►Neonatology team commenced CPR and baby intubated

Outcome of mother following perimortem caesarean

►Prompt return of maternal circulation post delivery

►Mother transferred to operating theatre

►Laparotomy, proceeding to total abdominal hysterectomy

Cause of Arrest

►Spontaneous uterine rupture with previously undiagnosed placenta percreta

►Patient developed severe metabolic acidosis and DIC

►Massive haemorrhage -40 litre blood loss

Mother and Baby

►Mother transferred to ICU post operatively

►Followed by transfer to rehabilitation facility for 4 weeks post event

►Baby Owen spent 7days in NICU, two weeks in HDU,

►Discharged home into the care of his aunty

A Happy Family Portrait

Acknowledgements and thanks

►Dr. Nolan McDonnell- Consultant Anaesthetist

►Jenny Owen – Midwifery Educator

►The whole collaborative team that worked tirelessly throughout the night.

QUESTIONS???

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